Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Alpha-1-Antitrypsin, Serum LC

Facility

$181.00

Service Code	CPT 82103
Hospital Charge Code	1905910
Hospital Revenue Code	301
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Aetna of AZ Medicare	$50.68
Rate for Payer: AHCCCS Medicaid	$13.44
Rate for Payer: Allwell Medicaid	$13.44
Rate for Payer: Allwell Medicare	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicaid	$13.44
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicaid	$13.44
Rate for Payer: Banner UC Health Medicare	$27.15
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$123.08
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$117.65
Rate for Payer: Copperpoint Commercial	$44.80
Rate for Payer: Health Net of AZ Commercial	$108.60
Rate for Payer: Health Net of AZ Medicare	$50.68
Rate for Payer: Humana of AZ Medicare	$27.15
Rate for Payer: Mercy Care Medicaid	$13.44
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

Alpha-1-Antitrypsin, Serum LC

Facility

$181.00

Service Code	CPT 82103
Hospital Charge Code	1905910
Hospital Revenue Code	301
Min. Negotiated Rate	$47.06
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Cash Price	$144.80
Rate for Payer: Self Pay Self Pay	$144.80

ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL A

Facility

$237.00

Service Code	CPT 82107
Hospital Charge Code	23294368
Hospital Revenue Code	301
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Aetna of AZ Medicare	$66.36
Rate for Payer: AHCCCS Medicaid	$64.41
Rate for Payer: Allwell Medicaid	$64.41
Rate for Payer: Allwell Medicare	$35.55
Rate for Payer: Amerigroup Medicare	$35.55
Rate for Payer: APIPA Medicare/Medicaid	$88.52
Rate for Payer: AZCH Complete Medicaid	$64.41
Rate for Payer: AZCH Complete Medicare	$35.55
Rate for Payer: Banner UC Health Medicaid	$64.41
Rate for Payer: Banner UC Health Medicare	$35.55
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$161.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Copperpoint Commercial	$58.66
Rate for Payer: Health Net of AZ Commercial	$142.20
Rate for Payer: Health Net of AZ Medicare	$66.36
Rate for Payer: Humana of AZ Medicare	$35.55
Rate for Payer: Mercy Care Medicaid	$64.41
Rate for Payer: Self Pay Self Pay	$189.60
Rate for Payer: TriWest Medicare	$35.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$138.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.66

ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL A

Facility

$237.00

Service Code	CPT 82107
Hospital Charge Code	23294368
Hospital Revenue Code	301
Min. Negotiated Rate	$61.62
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Cash Price	$189.60
Rate for Payer: Self Pay Self Pay	$189.60

ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]

Facility

$0.75

Service Code	NDC 49884011074
Hospital Charge Code	205191087
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of AZ Commercial	$0.68
Rate for Payer: Aetna of AZ Medicare	$0.21
Rate for Payer: Allwell Medicare	$0.11
Rate for Payer: Amerigroup Medicare	$0.11
Rate for Payer: APIPA Medicare/Medicaid	$0.28
Rate for Payer: AZCH Complete Medicare	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.51
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of AZ Commercial	$0.49
Rate for Payer: Copperpoint Commercial	$0.19
Rate for Payer: Health Net of AZ Commercial	$0.45
Rate for Payer: Health Net of AZ Medicare	$0.21
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Self Pay Self Pay	$0.60
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.14

ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]

Facility

$0.75

Service Code	NDC 49884011074
Hospital Charge Code	205191087
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of AZ Commercial	$0.68
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Cash Price	$0.60
Rate for Payer: Self Pay Self Pay	$0.60

ALPRAZolam 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904586061
Hospital Charge Code	105910004
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

ALPRAZolam 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904586061
Hospital Charge Code	105910004
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

alteplase 100 mg IV Inj [CQCH]

Facility

$9,069.76

Service Code	HCPCS J2997
Hospital Charge Code	105910209
Hospital Revenue Code	636
Min. Negotiated Rate	$2,358.14
Max. Negotiated Rate	$8,162.78
Rate for Payer: Aetna of AZ Commercial	$8,162.78
Rate for Payer: Bisbee Police All Plans	$2,358.14
Rate for Payer: Cash Price	$7,255.81
Rate for Payer: Self Pay Self Pay	$7,255.81

alteplase 100 mg IV Inj [CQCH]

Facility

$9,069.76

Service Code	HCPCS J2997
Hospital Charge Code	105910209
Hospital Revenue Code	636
Min. Negotiated Rate	$140.86
Max. Negotiated Rate	$8,162.78
Rate for Payer: Aetna of AZ Commercial	$8,162.78
Rate for Payer: Aetna of AZ Medicare	$2,539.53
Rate for Payer: AHCCCS Medicaid	$140.86
Rate for Payer: Allwell Medicaid	$140.86
Rate for Payer: Allwell Medicare	$1,360.46
Rate for Payer: Amerigroup Medicare	$1,360.46
Rate for Payer: APIPA Medicare/Medicaid	$3,387.56
Rate for Payer: AZCH Complete Medicaid	$140.86
Rate for Payer: AZCH Complete Medicare	$1,360.46
Rate for Payer: Banner UC Health Medicaid	$140.86
Rate for Payer: Banner UC Health Medicare	$1,360.46
Rate for Payer: Bisbee Police All Plans	$2,358.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$6,167.44
Rate for Payer: Cash Price	$7,255.81
Rate for Payer: Cash Price	$7,255.81
Rate for Payer: Cigna of AZ Commercial	$6,348.83
Rate for Payer: Copperpoint Commercial	$2,244.77
Rate for Payer: Health Net of AZ Commercial	$5,441.86
Rate for Payer: Health Net of AZ Medicare	$2,539.53
Rate for Payer: Humana of AZ Medicare	$1,360.46
Rate for Payer: Mercy Care Medicaid	$140.86
Rate for Payer: Self Pay Self Pay	$7,255.81
Rate for Payer: TriWest Medicare	$1,360.46
Rate for Payer: UnitedHealth Group of AZ Commercial	$5,287.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,632.56

alteplase 2 mg IV Inj [CQCH]

Facility

$149.62

Service Code	HCPCS J2997
Hospital Charge Code	105910142
Hospital Revenue Code	250
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$140.86
Rate for Payer: Aetna of AZ Commercial	$134.66
Rate for Payer: Aetna of AZ Medicare	$41.89
Rate for Payer: AHCCCS Medicaid	$140.86
Rate for Payer: Allwell Medicaid	$140.86
Rate for Payer: Allwell Medicare	$22.44
Rate for Payer: Amerigroup Medicare	$22.44
Rate for Payer: APIPA Medicare/Medicaid	$55.88
Rate for Payer: AZCH Complete Medicaid	$140.86
Rate for Payer: AZCH Complete Medicare	$22.44
Rate for Payer: Banner UC Health Medicaid	$140.86
Rate for Payer: Banner UC Health Medicare	$22.44
Rate for Payer: Bisbee Police All Plans	$38.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$101.74
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna of AZ Commercial	$97.25
Rate for Payer: Copperpoint Commercial	$37.03
Rate for Payer: Health Net of AZ Commercial	$89.77
Rate for Payer: Health Net of AZ Medicare	$41.89
Rate for Payer: Humana of AZ Medicare	$22.44
Rate for Payer: Mercy Care Medicaid	$140.86
Rate for Payer: Self Pay Self Pay	$119.70
Rate for Payer: TriWest Medicare	$22.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$87.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$26.93

alteplase 2 mg IV Inj [CQCH]

Facility

$149.62

Service Code	HCPCS J2997
Hospital Charge Code	105910142
Hospital Revenue Code	250
Min. Negotiated Rate	$38.90
Max. Negotiated Rate	$134.66
Rate for Payer: Aetna of AZ Commercial	$134.66
Rate for Payer: Bisbee Police All Plans	$38.90
Rate for Payer: Cash Price	$119.70
Rate for Payer: Self Pay Self Pay	$119.70

alteplase 50 mg REC[CQCH]

Facility

$4,026.16

Service Code	HCPCS J2997
Hospital Charge Code	193296755
Hospital Revenue Code	636
Min. Negotiated Rate	$1,046.80
Max. Negotiated Rate	$3,623.54
Rate for Payer: Aetna of AZ Commercial	$3,623.54
Rate for Payer: Bisbee Police All Plans	$1,046.80
Rate for Payer: Cash Price	$3,220.93
Rate for Payer: Self Pay Self Pay	$3,220.93

alteplase 50 mg REC[CQCH]

Facility

$4,026.16

Service Code	HCPCS J2997
Hospital Charge Code	193296755
Hospital Revenue Code	636
Min. Negotiated Rate	$140.86
Max. Negotiated Rate	$3,623.54
Rate for Payer: Aetna of AZ Commercial	$3,623.54
Rate for Payer: Aetna of AZ Medicare	$1,127.32
Rate for Payer: AHCCCS Medicaid	$140.86
Rate for Payer: Allwell Medicaid	$140.86
Rate for Payer: Allwell Medicare	$603.92
Rate for Payer: Amerigroup Medicare	$603.92
Rate for Payer: APIPA Medicare/Medicaid	$1,503.77
Rate for Payer: AZCH Complete Medicaid	$140.86
Rate for Payer: AZCH Complete Medicare	$603.92
Rate for Payer: Banner UC Health Medicaid	$140.86
Rate for Payer: Banner UC Health Medicare	$603.92
Rate for Payer: Bisbee Police All Plans	$1,046.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,737.79
Rate for Payer: Cash Price	$3,220.93
Rate for Payer: Cash Price	$3,220.93
Rate for Payer: Cigna of AZ Commercial	$2,818.31
Rate for Payer: Copperpoint Commercial	$996.47
Rate for Payer: Health Net of AZ Commercial	$2,415.70
Rate for Payer: Health Net of AZ Medicare	$1,127.32
Rate for Payer: Humana of AZ Medicare	$603.92
Rate for Payer: Mercy Care Medicaid	$140.86
Rate for Payer: Self Pay Self Pay	$3,220.93
Rate for Payer: TriWest Medicare	$603.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,347.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$724.71

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0521
Min. Negotiated Rate	$13,677.30
Max. Negotiated Rate	$13,677.30
Rate for Payer: AHCCCS Medicaid	$13,677.30
Rate for Payer: Allwell Medicaid	$13,677.30
Rate for Payer: AZCH Complete Medicaid	$13,677.30
Rate for Payer: Banner UC Health Medicaid	$13,677.30
Rate for Payer: Mercy Care Medicaid	$13,677.30

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0524
Min. Negotiated Rate	$13,677.30
Max. Negotiated Rate	$13,677.30
Rate for Payer: AHCCCS Medicaid	$13,677.30
Rate for Payer: Allwell Medicaid	$13,677.30
Rate for Payer: AZCH Complete Medicaid	$13,677.30
Rate for Payer: Banner UC Health Medicaid	$13,677.30
Rate for Payer: Mercy Care Medicaid	$13,677.30

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0522
Min. Negotiated Rate	$5,836.35
Max. Negotiated Rate	$5,836.35
Rate for Payer: AHCCCS Medicaid	$5,836.35
Rate for Payer: Allwell Medicaid	$5,836.35
Rate for Payer: AZCH Complete Medicaid	$5,836.35
Rate for Payer: Banner UC Health Medicaid	$5,836.35
Rate for Payer: Mercy Care Medicaid	$5,836.35

Alteration In Consciousness

Facility

$4,524.03

Service Code	APR-DRG 0522
Hospital Charge Code	APRDRG0524
Min. Negotiated Rate	$4,524.03
Max. Negotiated Rate	$4,524.03
Rate for Payer: AHCCCS Medicaid	$4,524.03
Rate for Payer: Allwell Medicaid	$4,524.03
Rate for Payer: AZCH Complete Medicaid	$4,524.03
Rate for Payer: Banner UC Health Medicaid	$4,524.03
Rate for Payer: Mercy Care Medicaid	$4,524.03

Alteration In Consciousness

Facility

$4,524.03

Service Code	APR-DRG 0522
Hospital Charge Code	APRDRG0523
Min. Negotiated Rate	$4,524.03
Max. Negotiated Rate	$4,524.03
Rate for Payer: AHCCCS Medicaid	$4,524.03
Rate for Payer: Allwell Medicaid	$4,524.03
Rate for Payer: AZCH Complete Medicaid	$4,524.03
Rate for Payer: Banner UC Health Medicaid	$4,524.03
Rate for Payer: Mercy Care Medicaid	$4,524.03

Alteration In Consciousness

Facility

$4,524.03

Service Code	APR-DRG 0522
Hospital Charge Code	APRDRG0521
Min. Negotiated Rate	$4,524.03
Max. Negotiated Rate	$4,524.03
Rate for Payer: AHCCCS Medicaid	$4,524.03
Rate for Payer: Allwell Medicaid	$4,524.03
Rate for Payer: AZCH Complete Medicaid	$4,524.03
Rate for Payer: Banner UC Health Medicaid	$4,524.03
Rate for Payer: Mercy Care Medicaid	$4,524.03

Alteration In Consciousness

Facility

$4,026.04

Service Code	APR-DRG 0521
Hospital Charge Code	APRDRG0522
Min. Negotiated Rate	$4,026.04
Max. Negotiated Rate	$4,026.04
Rate for Payer: AHCCCS Medicaid	$4,026.04
Rate for Payer: Allwell Medicaid	$4,026.04
Rate for Payer: AZCH Complete Medicaid	$4,026.04
Rate for Payer: Banner UC Health Medicaid	$4,026.04
Rate for Payer: Mercy Care Medicaid	$4,026.04

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0523
Min. Negotiated Rate	$13,677.30
Max. Negotiated Rate	$13,677.30
Rate for Payer: AHCCCS Medicaid	$13,677.30
Rate for Payer: Allwell Medicaid	$13,677.30
Rate for Payer: AZCH Complete Medicaid	$13,677.30
Rate for Payer: Banner UC Health Medicaid	$13,677.30
Rate for Payer: Mercy Care Medicaid	$13,677.30

Alteration In Consciousness

Facility

$4,026.04

Service Code	APR-DRG 0521
Hospital Charge Code	APRDRG0523
Min. Negotiated Rate	$4,026.04
Max. Negotiated Rate	$4,026.04
Rate for Payer: AHCCCS Medicaid	$4,026.04
Rate for Payer: Allwell Medicaid	$4,026.04
Rate for Payer: AZCH Complete Medicaid	$4,026.04
Rate for Payer: Banner UC Health Medicaid	$4,026.04
Rate for Payer: Mercy Care Medicaid	$4,026.04

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0521
Min. Negotiated Rate	$5,836.35
Max. Negotiated Rate	$5,836.35
Rate for Payer: AHCCCS Medicaid	$5,836.35
Rate for Payer: Allwell Medicaid	$5,836.35
Rate for Payer: AZCH Complete Medicaid	$5,836.35
Rate for Payer: Banner UC Health Medicaid	$5,836.35
Rate for Payer: Mercy Care Medicaid	$5,836.35

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0523
Min. Negotiated Rate	$5,836.35
Max. Negotiated Rate	$5,836.35
Rate for Payer: AHCCCS Medicaid	$5,836.35
Rate for Payer: Allwell Medicaid	$5,836.35
Rate for Payer: AZCH Complete Medicaid	$5,836.35
Rate for Payer: Banner UC Health Medicaid	$5,836.35
Rate for Payer: Mercy Care Medicaid	$5,836.35

Know your out-of-pocket cost for care.

All Charges